Diabetes Management
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Adherence to treatment guidelines in Type 2 diabetes patients failing metformin monotherapy in a real-world setting Kaan Tunceli1, Inbal Goldshtein2, Shengsheng Yu1, Ofer Sharon1, Kimberly Brodovicz1, Noga Gadir1, Harvey Katzeff1, Bernd Voss1, Larry Radican1, Gabriel Chodick2,3, Varda Shalev2,3, Yasmin Maor3,4 & Avraham Karasik*,3,4 Summary points
Background ●●
The importance of proactive diabetes treatment has been reinforced by recent diabetes guidelines. Understanding
the magnitude of clinical inertia in a real world cohort of patients with Type 2 diabetes mellitus, and understanding the factors affecting intensity of care may improve diabetes care. Results ●●
Overall, 7705 patients were identified in a large computerized database of an Israeli HMO, in whom HbA1c
>7% was measured for the first time following at least 90 days on metformin therapy. Of these, 56% (n = 4336) changed treatment within 1-year, by increasing metformin dose (36%), adding drugs (60%), or switching to other medications (4%). ●●
Strongest predictors of change were higher HbA1c, younger age and higher socioeconomic status (SES).
Conclusion ●●
In this cohort, the extent of inertia appears to be smaller than that reported in previous studies. The may be due to intensive implementation of guidelines.
SUMMARY Aim: To describe the drug management of T2DM patients in a real life cohort with suboptimal HbA1c after treatment with metformin monotherapy. Methods: we performed a retrospective cohort analysis of computerized medical records after measuring an HbA1c >7% for the first time following at least 90 days on metformin therapy. Results: Among 7705 eligible patients, 56% (n = 4336) changed treatment within 1-year, by increasing metformin dose (36%), adding drugs (60%), or switching to other medications (4%). Strongest predictors of change were higher HbA1c, younger age and higher socioeconomic status (SES). Conclusion: In this cohort, the extent of inertia appears to be smaller than that reported in previous studies. Nonetheless, disease management programs aimed at improving guideline adherence and reducing inertia are still warranted.
Merck & Co, Inc., Whitehouse Station, NJ 08889, USA Maccabi Healthcare Services, Tel Aviv, Israel 3 Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel 4 Sheba Medical Center, Tel Hashomer, Israel *Author for correspondence: Tel.: +972 3530 2815; Fax: +972 3530 2083;
[email protected] 1 2
10.2217/DMT.14.45 © 2015 Future Medicine Ltd
Diabetes Manag. (2015) 5(1), 17–24
part of
ISSN 1758-1907
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Research Article Tunceli, Goldshtein, Yu et al. KEYWORDS
• ADA/EASD guidelines • clinical inertia • personalized medicine
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Type 2 diabetes mellitus (T2DM) is one of the most common diseases worldwide [1] . Diabetes is a progressive disease that causes microvascular and macro vascular complications [2] . These complications significantly decrease patient quality of life and increase morbidity and mortality. National and international diabetes management guidelines consistently emphasize the importance of glycemic control to prevent these complications. Metformin, a biguanide, is considered the first choice for oral treatment of T2DM in patients without contraindications [3] . Metformin primarily decreases hepatic glucose output and increases insulin-mediated glucose utilization in peripheral tissues particularly after meals. Metformin also has an antilipolytic effect that lowers serum-free fatty acid concentrations, thereby reducing substrate availability for gluconeogenesis. In obese patients, treatment with metformin results in a modest weight reduction. In addition, metformin compared with other drugs used for treating T2DM is less likely to cause hypoglycemia. Metformin typically lowers fasting blood glucose concentrations by approximately 20% and HbA1c by 1.5% [4–6] . The American Diabetes Association (ADA) together with the American College of Cardiology and the American Heart Association, recommends HbA1c 125 mg/dL (6.9 mmol/l), or had purchased antihyperglycemic medication twice within the last 2 months. Patients are identified by an automated database search and therefore the registry is not dependent on physicians actively reporting on the patient to the registry. Electronic patient records of diabetic patients 18–89 years old who had a dispensed prescription for metformin during 2009–2011 were screened for study eligibility. Inclusion criteria were all patients in the diabetes registry who have been receiving metformin monotherapy for at least 90 continuous days prior to an available HbA1c result of >7%. The date of the HbA1c measurement was defined as the index date. Patients which were not continuously enrolled in MHS for at least 12 months prior to and 12 months following the index date were excluded (see Appendix 1 for patient selection process). Cardiovascular disease (CVD) was defined as occurrence of myocardial infarction or performance of cardiac revascularizations by percutaneous coronary intervention or coronary artery bypass grafting as reported from hospital charge records, as indicated in the MHS’ registry of cardiovascular patients [13] . Renal impairment at baseline was defined as at least one eGFR test
